R 6067 lo�oo /i .ePERMIT
ve
APPLICATION FOR CITY OF CUPERTINO
NUMBER R- .6067
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
•.
IN DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS G l e v 6,"a ek
O isr0 ('l RESIDENTIAL COMMERCIAL OTHER
OWNER'S •HAZARDOUS FIRE AREA
VES ❑ It yes-I understand that a Class A
NAME U /v root assembly is required.
_ NO ❑ InNal I.C.B.O.k
Aoonese �3 �/ OCIn�/N GHQ S EXISTING ROOF COVERING
PHONE 1] SD p � C) NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
�q / /r /
NAME_ ( J Il l _J/MJ fill (A \CA TO BE REMOVED V TO BE RETAINED
ADDRESS (y (� / ( I_ �r G -r _ / - TYPE OF ROOF COVERING'
CITY&ZIP !S u (A o Gt
EXISTING
PHONE 7� -� �(nZlll/ BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES '
7000)of Division 3 of the Business and Professions Code,and my license is In full force and
effect. ❑
License Close � Lic.Number v 2 173 WOOD SHINGLES/
�f— 2 S
Date OTHER(SPECIFY) ❑
Contractor
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors License Law for the following reason. / s
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to v
construct,alter,Improve,demolish,or repair any structure,prior to Its issuance,also requires the BUILT-UP ROOF El
for such permit to file a signed statement that he Is licensed pursuant to the provisions - /
at the Contractor's License Law(Chapter B(commencing with Section 7000)of Division 3 of the -
•
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500).):
❑I,as owner of the properly,or my employees with wages as their Bole compensatl[not
WOeS S ❑ A�
the work,and the structure Is not Intended or offered for sale(Sec.7044,Buslnesa an
slons Code:The Contractor's License Lew does not apply to an owner of property who WOOD SH LES /
improves thereon,and who does such work himself or through his own employees,prm ❑
such improvements are not Intended or offered for sale,it,however,the building or I 'oq
Is sold within one year of completion,the owner-builder will have the burden of proving tq� �$S lFY) ❑
not build or Improve for purpose of sale.).
C]1,as owner of the property,am exclusively contracting with licensed contractors to
the project(Sec.704,Business and Professions Code:The Contractor's License Law PROVIDE I.C. .0.REPORT NO.
apply to an owner of property who builds or improves thereon,and who contracts for sucwith a contractor(e)licensed pursuant to the Contractor's License Law. R.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B$P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
Q I have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, Bllllding G•
as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which this
permit is Issued. (� a Seismic 1 have and will maintain Workers Compensation Insurance,as required by Section 3700 of 7._ �] 2l S
80
.the Labor Code,for the performance of the work for which this permit is Issued.My Worker's IJ / J (2- 1,10,q O
Compensa1tio�n,Insurance carrier and Policy number are: Total l ,O
Carrier LL^G[awl Irt1C Policy No. 1— PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C. p
(This section need not be completed If the permit Is for one hundred dollars(E100)or leas.) /t 'T !"1 ,/ -2G
I certify that in the performance of the work for which this permit Is issued,I shall not employ- /� r !-� r/
any person In any manner so as to become subject to the Workers'Compensation Laws of Cali. All roofs shall be inspected prior to any roofing material being
fornia. C' installed. If a roof is installed without first obtaining an
Date $—Z s—� Apr caul ��GGiK iYQ1�iC inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this tificale of Exemption,you should become Applicant understands and, will comply
subject to the Workere'Compensatlon provisions of the Labor Code,you must forthwith comply PP ply with all non point
with such provisions or this permit shalpbe deemed revoked. Source regulations.
1 certify that I have read this application and state that the above Information is correct.I agree
to comply with all city and county ordinances and state laws relating to building construction,and All root coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in. A •��^
spection purposes. /VVd� �e C J-"�
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities, �L.C�(/r/ l
judgments,costa and expenses which may In any way accrue against said City In consequence
. of the granting of this permit. SIGN URE OF APPLICANT DATE
PRE-INSPECTION. PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP.—DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE INSP. -DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION .
OFFICE COPY